PEM POCUS Series: Confirmation of Endotracheal Tube Placement

PEM POCUS endotracheal tube confirmation badge

Read this tutorial on the use of point of care ultrasonography (POCUS) for confirmation of endotracheal tube (ETT) placement in pediatric patients. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.

Take the ALiEMU PEM POCUS: Pediatric ETT Confirmation Quiz

Module Goals

  1. List indications for performing airway/lung POCUS to confirm ETT placement
  2. Describe the technique of performing airway and focused lung POCUS
  3. Distinguish between normal and abnormal airway and lung POCUS findings
  4. Distinguish between tracheal, endobronchial, and esophageal placement of ETT
  5. List the limitations of airway and lung POCUS

Case Introduction: The Postictal Toddler

Joey is a 2-year-old male with a history of epilepsy who presents to a community hospital emergency department with generalized tonic-clonic seizures of more than 45 minutes duration. After receiving 2 doses of IV midazolam, he stopped seizing. He has very shallow breathing and oxygen saturations as low as 90 percent on 2 liters of supplemental oxygen via nasal cannula. The pediatric transport team arrives to transport him to another hospital for admission and note that he is somnolent with poor respiratory effort. His current vital signs:

Vital SignFinding
Temperature37.0 C
Heart Rate115 bpm
Blood Pressure85/65
Respiratory Rate12
Oxygen Saturation (room air)92% on 2 L via nasal cannula

An end tidal carbon dioxide (ETCO2) monitor shows a ETCO2 level in the high 70s mmHg. The decision is made to intubate the patient given disordered breathing, hypercapnia, and hypoxia following medical management of seizures. The transport team would like to use POCUS to evaluate ETT placement at the outside hospital and during transport.

For simplicity, this module will focus on 3 modes of using POCUS for ETT confirmation. Collectively, these techniques can help improve evaluation.

There are many benefits of using POCUS to confirm ETT placement, such as in the following examples:

  • When compared to auscultation, POCUS ETT can be done in a loud environment where auscultation may be challenging (i.e., as may occur in transport or on scene).
  • When compared to radiography, POCUS ETT can be done rapidly at the bedside when chest radiography may be delayed or unavailable (i.e., in transport or during chest compressions).
  • When compared to capnography, POCUS ETT is helpful in scenarios of low pulmonary blood flow as in cardiac arrest or with poor tissue perfusion when capnography may be less reliable. Also POCUS can distinguish between tracheal and endobronchial ETT placement, whereas capnography cannot.
  • Unlike auscultation and capnography, POCUS ETT can confirm placement in real time, even before ventilating the patient, unlike auscultation and capnography to work.
  • POCUS ETT should typically be used as an adjunct to other methods of confirmation or in resource-limited settings, if other methods are not available.

Just as all methods of confirming ETT placement have their limitations, so does POCUS. This will be discussed in greater detail later in the module.

There are many factors to consider in the performance of ETT POCUS:

FactorOptions
Probe selectionLinear or curvilinear
Location on the anterior neckSuprasternal notch, cricoid, or thyroid cartilage
Probe orientationLongitudinal or transverse plane
TimingDynamic (while intubating) or static (for confirmation)
Evaluation techniqueDirect (visualize the ETT) or indirect (visualize lung movement0

Probe Selection

Two types of probes will be needed for POCUS ETT confirmation.

  • Use a linear probe to visualize the superficial airway and lung structures. The linear probe uses high frequency sound waves to create high resolution images of superficial structures such as the trachea and pleura.
  • Use a curvilinear probe to visualize deeper structures, such as the diaphragm. The curvilinear probe uses lower frequency sound waves to create higher resolution images of deeper structures.
POCUS ultrasound probes

Figure 1: Linear probe (left) and curvilinear probe (right)

Timing of Image Acquisition

If time permits, pre-scan the patient’s neck to locate the trachea. Adjust the gain and depth accordingly to visualize the trachea clearly in the middle of the screen.

pocus neck trachea endotracheal tube ett

Figure 2: Positioning and ultrasound images of the anterior neck anatomy for ETT placement confirmation. Left: Transverse orientation of the linear probe just above the suprasternal notch. Center: Corresponding pictorial display of the trachea and surrounding structures. Note that below the trachea is a dirty shadow artifact, resulting from the air-mucosa interface. Right: Corresponding ultrasound image of the thyroid lobes flanking the empty trachea, with the ovoid esophagus seen posterolaterally (ultrasound image by Jade Sequin).

1. Static Assessment

  • We recommend using the static assessment (i.e., after the patient is intubated), rather than dynamic (i.e., watching the ETT enter the trachea in real time) which is technically more challenging.
  • Positioning: Stand at the patient’s waist, facing the patient’s head, with the probe marker pointing towards the patient’s right (transverse plane) to confirm ETT placement in the neck. Place the linear transducer midline on the anterior neck, slightly above the suprasternal notch (figure 2, left). The orientation of the image on the screen corresponds to the probe direction. This orientation is helpful for procedural POCUS and conceptually allows for easier redirection.
  • Identify the trachea: The trachea is visible in the midline as a semicircular structure with a hyperechoic bright line (upside down U) and shadows distally (figure 2, center). Shadows are reverberation artifact from the air in the trachea (often called “dirty shadows,” or referred to as the air-mucosa interface). The thyroid overlies the trachea as a homogenous structure with the lobes extending bilaterally.
  • Identify the esophagus: The esophagus is generally posterolateral and to the left of the trachea. The esophagus is seen as a collapsed round or oval shaped structure with concentric layers, without air in it (figure 2, right).
    • Anatomy variability: A pediatric study noted that the esophagus can be seen in variable locations in relation to the cricoid ring and trachea. It was partially to the patient’s left (62%), completely to the left (20%), behind the cricoid ring (16%), and partially to the right (2%) [1].

When the ETT is placed correctly in the trachea, you should still see only a SINGLE air-mucosa interface, similar to an empty trachea. An ETT properly positioned in the trachea will have a similar ultrasonographic appearance with one air-mucosal interface as the air-filled tube will be in the trachea and the esophagus will be decompressed without air (figure 2, right).

2. Dynamic Assessment

Dynamic assessment involves watching the ETT pass into the trachea in real-time. In this technique, you will see a brief disturbance within the trachea termed the “snowstorm” which is a subtle finding (Video 1). A dynamic assessment is made more challenging with the multiple tasks and personnel at the bedside during intubation.

Video 1: Dynamic assessment of ETT placement confirmation using a linear probe in the transverse orientation on the anterior neck . With the probe marker to the patient’s right, the trachea is often on the left of the screen in relationship to the esophagus, as in this video. As the ETT enters the trachea, there is a slight disruption termed a “snowstorm” noted in this dynamic view. Video credit: Jade Sequin

Erroneous Esophageal Intubation

If the ETT is placed incorrectly in the esophagus, there will be TWO air-mucosa interfaces with reverberation artifact and posterior shadowing. This has been called the “double trachea sign” or “double tract sign” (figure 3, left). Contrast this to normal anatomy with an empty esophagus (figure 3, right).

Figure 3. Left: Double tract or double trachea sign on ultrasound, visualized when the ETT is placed incorrectly in the esophagus. Note the esophagus appears curved with dirty shadow artifact like the trachea. Right: Normal collapsed esophagus. Images credit: Jade Sequin.

Video 2: Esophageal intubation seen on ultrasound. Note the ETT entering the esophagus, generating the “double tract” or “double trachea” sign. Video used with permission by authors of [2].
Video 3: “Double tract” or “double trachea” sign and esophageal de-intubation. The video starts with the ETT in the esophagus, but then is removed. Video used with permission by authors of [2].

This indirect visualization method uses ultrasound to identify bilateral lung sliding as a means to confirm ETT placement, because this implies that both lungs are ventilated. This method is often used in conjunction with and after direct confirmation using POCUS, seeing the ETT in the trachea.

  • If the ETT is in the right main stem bronchus, ONLY the right lung will have sliding.

Ultrasound Probe Placement

Place the linear transducer on the superior, most-anterior chest wall in the mid clavicular line over the 3rd-5th intercostal space. Ensure that the probe marker is towards the head. Scan both lungs (Figures 4).

pediatric lung sliding positioning

Figure 4. Positioning of the linear probe on the patient’s anterior chest wall to check for lung sliding

Normal Lung Findings on POCUS

ultrasound lung sliding landmarks

Figure 5. Ultrasound of a normal lung: Just deep to the chest wall and ribs, the pleural line of the lung slides horizontally to and fro with each breath.This line is the first hyperechoic line deep to the rib and is the place to look for lung sliding.

Alveoli filled with air have the ARTIFACTS that are the hallmark of airway POCUS.

  • A lines (figure 6): Hyperechoic lines that are parallel to the pleural line (typically horizontal) that are caused by reverberations between the pleura and transducer. They are equidistant from the chest wall. A lines are seen with normal aerated lungs along with lung sliding
  • Z lines or comet tails: Perpendicular lines to the pleura (often appear vertical as the pleura is typically visualized as horizontal) that arise from the pleura. These lines typically do not go to the bottom of the screen.
  • Lung sliding (figure 8): Shimmering artifact of the parietal and visceral pleura sliding against each other. Lung sliding indicates that the lung visualized under the probe is filled with air and ventilated (video 4).

Figure 6. Normal lung with A lines – The most superficial hyperechoic line below the chest wall is the pleural line. The subsequent hyperechoic lines parallel and deep to the pleural line are A lines. A lines are always normal findings.

Video 4: Normal lung ultrasound: Most superficial are the chest wall tissue and 2 ribs (the circular anechoic structures). The hyperechoic line just deep to the ribs is the pleural line. Lung sliding is the subtle movement at the pleural line, referred to as “ants marching.” The hyperechoic lines horizontal and parallel to the pleural line are A lines, and the thin vertical lines are Z lines, or comet tails.

B Lines

In contrast to A lines, B lines may be visualized in patients with abnormal lungs. B lines are hyperechoic lines (typically vertical) that arise at the pleural line and go all the way to the bottom of the screen (at least 4-8 cm depth with some experts recommending to 16 cm). This is in contrast to Z lines which do not go to the bottom of the screen. The presence of multiple B lines indicates increased fluid in the interstitium of the lungs, which can be seen in conditions such as bronchiolitis and pulmonary edema (figure 7, videos 5 and 6). Note that the presence of B lines also indicate aerated lungs.

Figure 7. Lung POCUS showing A and B lines. A lines are the hyperechoic lines parallel to the pleural line. B lines are the hyperechoic projections perpendicular to the pleural line that extends to the bottom of the screen. A lines are normal, while multiple B lines may be pathogenic.

Video 5: Lung ultrasound showing multiple hyperechoic, perpendicular B lines.
Video 6: Lung ultrasound showing lung sliding and multiple B lines. Note that this image uses a curvilinear probe.

M-Mode Setting

For additional confirmation of lung sliding, press the M mode button (motion mode) without lifting the probe to visualize motion of the sliding pleura. The M-mode view represents a small narrow slice of the ultrasound image (where the bold white vertical line appears) and runs only that portion over time.

  • Lung is aerated: Looking below the pleural line level ,you will see a grainy display, known as the “sandy beach” or “seashore” signs (figure 8). You’ll find yourself feeling very relaxed when you see this, because this indicates a successfully aerated lung.
  • Lung is NOT aerated: Looking below the pleural line level, you will see multiple horizontal bar-like, striated lines instead of the grainy, sandy beach (figure 9). This is called the “barcode” or “stratosphere” sign, and may be seen in a pneumothorax or a main-stem bronchus intubation.

Figure 8: Lung ultrasound with M-mode view in a normal, aerated lung (left), showing the grainy, “sandy beach” appearance of the lines deep to the pleural line. Contrast this to an abnormal, non-aerated lung (right), showing the horizontal “barcode” appearance of the lines deep to the pleural line.

Figure 9: Another example of a normal (left) and non-aerated (right lung) in M-mode view

Ultrasound Technique

Visualize lung sliding in both 2D (also known as B mode and is the typical ultrasound mode) and M mode on the both the left and right chest.

  • Note: If the ETT is in the right mainstem bronchus, you may still see subtle movements of the pleural line on the left due to cardiac activity. The lung sliding in this case will be asymmetric with less movement of the pleural line on the left compared to right.

Alternative Causes for Abnormal Lung Sliding After Intubation

Abnormal lung sliding on ultrasound may be worrisome for an esophageal intubation, because the lungs are not aerated with PPV breaths. However, there are other causes to consider before removing the ETT for a re-intubation attempt.

1. Pneumothorax

In order to see lung sliding, visceral and parietal pleural need to be touching. With a pneumothorax, there is air in the pleural space. The parietal pleura will still be visible, but the visceral pleura and moving interface are not seen. In the M-mode view, a “barcode sign” will be present (figure 10), highlighting the importance of evaluating both 2D (B mode) and M mode if there is any doubt about lung sliding.

Figure 10: Lung POCUS demonstrating no lung sliding (“barcode sign”) in M-mode view

Video 10: Lung POCUS of a patient with a pneumothorax, showing no lung sliding for one lung in 2D view (B mode)

2. Main stem bronchus intubation

If there is no lung sliding in just one lung (especially if it occurs on the left), this may be caused by the ETT being too deep into a mainstem bronchus. This results in non-ventilation of the contralateral lung. Be aware that since the visceral and parietal pleural are still touching (unless there is also a pneumothorax), you could see some sliding movement, as the heart still causes some movement of the lungs.

3. ETT obstruction or apnea

This results in the loss of lung sliding bilaterally.

Take Away

When you see symmetric lung sliding on both sides of the chest, the ETT is in good position in the trachea.

Ultrasound Probe Placement

Use a curvilinear probe, because it gives you deeper tissue penetration than the linear probe. This allows you to better visualize the diaphragm, which is a deeper structure.

Figure 11. Left: Using a curvilinear probe with the probe marker towards the head, position it along the mid-axillary line to identify the diaphragm. Continue sliding the probe to the lower edge of the ribcage until you see the diaphragm meeting the spine along the bottom of the ultrasound image. Right: Ideal ultrasound view of the hyperechoic diaphragm. Also seen is the liver with mixed echotexture, a hypoechoic kidney, and the hyperechoic spine.

Normal Findings on POCUS (figure 11)

  • The diaphragm is a hyperechoic line, seen curving vertically on the screen, with a solid organ (liver or spleen) caudal to that.
  • The spine appears as interrupted hyperechoic structures (vertebral bodies), extending caudally from the diaphragm at the bottom of the image. The vertebral bodies shadow as all calcified structures on ultrasound do. Normally the spine is only visualized caudal to the diaphragm, because aerated lung obscures visualizing the spine in the thorax (cephalad to the diaphragm).

Ultrasound Technique

  1. Watch the movement of the diaphragm. In a patient who is paralyzed for intubation, the diaphragm will only move with delivery of positive pressure ventilation (PPV).
    • Normal: If the ETT is in good position, with a PPV breath, the diaphragm moves caudal toward the abdomen as the lungs inflate, and upwards when the lungs deflate (video 7). In M mode, normal diaphragm movement creates a smooth wave with inspiration and expiration (video 8).
    • Esophageal intubation: The diaphragm moves in the reverse direction than is expected. With a PPV breath, the diaphragm moves cephalad, because the abdominal cavity is getting inflated.
    • Mainstem bronchus intubation: The diaphragm on the side of the main stem intubation (typically right) will show exaggerated motion toward the abdomen during PPV. The diaphragm on the contralateral side, where the lung is not properly ventilated will either not move or move paradoxically cephalad during PPV. In M-mode, there is no sinusoidal, wave pattern for the diaphragm in the non-ventilated lung (video 9)
Video 7: Ultrasound view showing diaphragmatic movement with regular breaths. The diaphragm pushes the spleen and kidneys caudal into the abdomen (to the right of the screen) with each breath.
Video 8: Ultrasound M-mode view of the diaphragm with regular breaths. Normal diaphragmatic movement is demonstrated by the hyperechoic sinusoidal line (at 12 cm depth) at the bottom of the screen.
Video 9: Ultrasound of the diaphragm in M-mode setting. The hyperechoic diaphragm does not move either in 2D (top) or M mode (bottom). This could be seen if the ETT is in the esophagus or in a mainstem bronchus, for example.

Abnormal Findings While Assessing Diaphragmatic Movement

1. Hemothorax or pleural effusion

Best seen at the costophrenic angle because fluid is dependent, a hemothorax or effusion will appear anechoic or hypoechoic. Additionally the spine can now be seen cephalad to the diaphragm, known as the “spine sign,” because air now no longer obscures the view of the spine (figure 12). A hemothorax and pleural effusion can look the same on POCUS. The clinical scenario aids in determining the potential cause of the fluid.

Figure 12. Left: Normal lung showing the spine only caudal to the hyperechoic diaphragm. Right: Hemothorax on lung POCUS. Right: Lung POCUS showing a pleural effusion, suggested by the hypoechoic fluid collection and “spine sign”.

Take Away

In a patient paralyzed for intubation and thus with no spontaneous respirations, the ETT is in good position when you see movement of the diaphragm towards the abdomen on both sides of the chest with PPV.

Lin et al. published a systematic review of bedside ultrasound for tracheal tube verification in pediatric patients. The authors proposed the following algorithm (figure 13) for confirming ETT placement.

Figure 13: Algorithm for using and interpreting POCUS to confirm ETT placement in pediatric patients. Image permission granted by author of [3].

  • Operator dependent: As with all POCUS studies, image acquisition and interpretation is operator dependent. The more you practice the concepts and techniques in this module, the more comfortable you will be in obtaining and accurately interpreting these images.
  • Challenging anatomy: It is difficult to perform airway POCUS on a small neck, with a cervical collar in place, or if there is subcutaneous emphysema (air obscures structures below).
  • Depth: Airway POCUS is not able to determine the exact depth of ETT within the trachea, but can be a good surrogate of position:
    • Visualization of the ETT cuff at the suprasternal notch using a linear probe in the transverse orientation correlated with the ETT depth on chest x-ray in 57/60 children (Cl, 86-98%) in a single center, prospective observational study [11]
    • If you are concerned about a mainstem bronchus intubation, slowly pull back on the ETT to see if the lung opposite the main stem intubation starts sliding. If the depth of the tube at the gums/teeth/lips seems appropriate and one side still does not have sliding, there may be a pneumothorax on that side.
  • False negative for ETT placement: In the rare patient with thyroid gland calcifications, there may falsely appear to be 2 shadowing structures (double tract sign), even when the ETT is correctly in the trachea. Calcifications shadow. This can be anticipated with pre-scanning the neck before intubation.
  • False positive for ETT placement: If the esophagus is structurally immediately posterior to the trachea, you wouldn’t see a “double tract” sign if the ETT is in the esophagus. But you should have other signs soon if the ETT is in the wrong place such as lack of ETCO2 and lack of breath sounds.
  • Lack of lung sliding may not always be due to pneumothorax or right mainstem ETT intubation. Other explanations include:
    • ETT obstruction
    • Apnea in a spontaneously breathing patient or no breath being delivered to a patient who is intubated.
    • Lack of sliding or “barcode” (on M-mode) should be interpreted with caution in patients who have parenchymal lung disease or pleurodesis (a procedure where the pleura is surgically or mechanically adhered to the chest wall) making the lung appear not to slide. These patients may not have pneumothorax nor a main stem intubation on the other side.

Adult Literature

In a metanalysis of 30 adult studies assessing the use of POCUS for ETT placement confirmation, the overall sensitivity was 0.98 (95% CI 0.97–0.99) and specificity was 0.96 (95% CI 0.90–0.98) [4].

Other studies have evaluated using various techniques for POCUS evaluation of ETT placement, with no clear winner (Table 1).

VariableSourceFindingsRecommendation
Probe type: Linear vs CurvilinearSahu 2020 [4]No differenceLinear probe
Technique: Static vs DynamicSahu 2020 [4] No differenceStatic technique
Probe placement:

  • Transverse at suprasternal notch
  • Longitudinal at cricoid or thyroid cartilage
Lonchena 2017 [5]Successful ETT visualization

  • Suprasternal notch: 100%
  • Cricoid: 70%
  • Thyroid: 40%
Place probe transverse in suprasternal notch in the anterior neck
Table 1: Published studies in the adult population, comparing different techniques for confirming ETT placement with POCUS.

Pediatric Literature

The pediatric literature for the application of POCUS to evaluate ETT placement is not as robust compared to adult studies; however, it is still compelling. A systematic review by Lin et al. in 2016 [3] included studies that evaluated intubations using direct visualization of tube tip in trachea, diaphragmatic movement and/or lung sliding. All modalities had high sensitivities though the esophageal intubation rates included in the studies were relatively low (Table 2).

StudyEndotracheal IntubEsophageal IntubPOCUS Technique UsedSensitivitySpecificity
Galicinao 2007 [6]501Direct visualization of tube tip in trachea1.00 (0.93-1.00)1.00 (0.03-1.00)
Alonso Quintela 2014 [7]315Direct visualization of tube tip in trachea0.92 (0.75-0.99)1.00 (0.48-1.00)
Hsieh 2004 [8]612Diaphragmatic or lung pleural movement1.00 (0.94-1.00)1.00 (0.16-1.00)
Kerrey 2009 [9]1270Diaphragmatic or lung pleural movement1.00 (0.97-1.00)Not reported
Table 2: Summary of pediatric studies that evaluated using POCUS for ETT confirmation by direct visualization of the tube in the trachea over the anterior neck or indirectly by assessing for diaphragmatic or pleural movement.

Another systematic review of using POCUS to confirm ETT position in the pediatric population by Jaeel et al [10], found that POCUS was comparable to confirming ETT placement by x-ray and capnography for patients outside the neonatal intensive care unit. They concluded that POCUS agreed with x-ray or capnography confirmation in 83-100% of cases. Compared to x-rays, POCUS had a sensitivity of 91-100%.

Case Resolution

After administration of fentanyl, midazolam, and rocuronium, the patient was intubated with a 4.0 cuffed ETT by direct laryngoscopy with a Macintosh blade.

POCUS was used to confirm ETT placement by the transport team in the community hospital ED. Specifically, the provider directly visualized the in the anterior neck (with a single air-mucosa interface), the presence of bilateral lung sliding, and movement of the diaphragm towards the abdomen with PPV. End tidal CO2 further confirmed accurate placement. Once loaded into the ambulance, the ETT was again confirmed to be in the trachea.

Video 11: POCUS showing bilateral lung sliding
Video 12. POCUS showing diaphragmatic movement down to the abdomen with breathing.

Learn More…

References

  1. Tsung JW, Fenster D, Kessler DO, Novik J. Dynamic anatomic relationship of the esophagus and trachea on sonography: implications for endotracheal tube confirmation in children. Journal of Ultrasound in Medicine. 2012 Sep;31(9):1365-70. PMID 22922616
  2. Tessaro MO, Salant EP, Arroyo AC, Haines LE, Dickman E. Tracheal rapid ultrasound saline test (TRUST) for confirming correct endotracheal tube depth in children. Resuscitation. 2015 Apr 1;89:8-12. PMID 25238740
  3. Lin MJ, Gurley K, Hoffmann B. Bedside Ultrasound for Tracheal Tube Verification in Pediatric Emergency Department and ICU Patients: A Systematic Review. Pediatr Crit Care Med. 2016;17(10):e469-e476. PMID 27487913
  4. Sahu AK, Bhoi S, Aggarwal P, et al. Endotracheal tube placement confirmation by ultrasonography: A systematic review and meta-analysis of more than 2500 patients. J Emerg Med. 2020 Aug 1;59(2):254-64. PMID 32553512
  5. Lonchena T, So S, Ibinson J, Roolf P, Orebaugh SL. Optimization of ultrasound transducer positioning for endotracheal tube placement confirmation in cadaveric model. J Ultrasound Med. 2017 Feb;36(2):279-84. PMID 28072483
  6. Galicinao J, Bush AJ, Godambe SA. Use of bedside ultrasonography for endotracheal tube placement in pediatric patients: A feasibility study. Pediatrics 2007; 120:1297–1303. PMID 18055679
  7. Alonso Quintela P, Oulego Erroz I, Mora Matilla M, et al: [Usefulness of bedside ultrasound compared to capnography and radiograph for tracheal intubation]. An Pediatr (Barc) 2014; 81:283–288. PMID 24560730 
  8. Hsieh KS, Lee CL, Lin CC, Huang TC, Weng KP, Lu WH. Secondary confirmation of endotracheal tube position by ultrasound image. Crit Care Med. 2004 Sep;32(9 Suppl):S374-7. PMID 15508663
  9. Kerrey BT, Ceis GL, Quinn AM. A prospective comparison of diaphragmatic ultrasound and chest radiography to determine endotracheal. Pediatrics. 2009;123:1039-43. PMID 19414520
  10. Jaeel P, Sheth M, Nguyen J. Ultrasonography for endotracheal tube position in infants and children. Eur J Pediatr. 2017 Mar;176(3):293-300. PMID 28091777
  11. Uya A, Gautam NK, Rafique MB, et al. Point-of-Care Ultrasound in Sternal Notch Confirms Depth of Endotracheal Tube in Children. Pediatr Crit Care Med. 2020;21(7):e393-e398. PMID 32168296

Additional Reading

  1. Adhikari S, Blaivas M. The Ultimate Guide to Point-of-Care Ultrasound-Guided Procedures. 1st Ed. Springer Nature; 2020.
  2. Blaivas M, Tsung JW. Point-of-care sonographic detection of left endobronchial main stem intubation and obstruction versus endotracheal intubation. J Ultrasound Med. 2008;27(5):785-789. doi:10.7863/jum.2008.27.5.785. PMID 18424655
  3. Chou EH, Dickman E, Tsou PY, et al. Ultrasonography for confirmation of endotracheal tube placement: a systematic review and meta-analysis. Resuscitation. 2015;90:97-103. doi:10.1016/j.resuscitation.2015.02.013. PMID 25711517
  4. Hoffmann B, Gullett JP, Hill HF, et al. Bedside ultrasound of the neck confirms endotracheal tube position in emergency intubations. Ultraschall Med. 2014;35(5):451-458. doi:10.1055/s-0034-1366014. PMID 25014479
  5. Lahham S, Baydoun J, Bailey J, et al. A Prospective Evaluation of Transverse Tracheal Sonography During Emergent Intubation by Emergency Medicine Resident Physicians. J Ultrasound Med. 2017;36(10):2079-2085. doi:10.1002/jum.14231. PMID 28503749
  6. Marciniak B, Fayoux P, Hébrard A, et al. Airway management in children: ultrasonography assessment of tracheal intubation in real time?. Anesth Analg. 2009;108(2):461-465. doi:10.1213/ane.0b013e31819240f5. PMID 19151273
  7. Mori T, Nomura O, Hagiwara Y, Inoue N. Diagnostic Accuracy of a 3-Point Ultrasound Protocol to Detect Esophageal or Endobronchial Mainstem Intubation in a Pediatric Emergency Department. J Ultrasound Med. 2019;38(11):2945-2954. doi:10.1002/jum.15000. PMID 30993739
  8. Prada G, Vieillard-Baron A, Martin AK, et al. Tracheal, Lung, and Diaphragmatic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care. J Cardiothorac Vasc Anesth. 2021;35(1):310-322. doi:10.1053/j.jvca.2019.11.051. PMID 31883769
  9. Sethi AK, Salhotra R, Chandra M, Mohta M, Bhatt S, Kayina CA. Confirmation of placement of endotracheal tube – A comparative observational pilot study of three ultrasound methods. J Anaesthesiol Clin Pharmacol. 2019;35(3):353-358. doi:10.4103/joacp.JOACP_317_18. PMID 31543584
  10. Sim SS, Lien WC, Chou HC, et al. Ultrasonographic lung sliding sign in confirming proper endotracheal intubation during emergency intubation. Resuscitation. 2012;83(3):307-312. doi:10.1016/j.resuscitation.2011.11.010. PMID 22138058
  11. Singh M, Chin KJ, Chan VW, Wong DT, Prasad GA, Yu E. Use of sonography for airway assessment: an observational study. J Ultrasound Med. 2010;29(1):79-85. doi:10.7863/jum.2010.29.1.79. PMID 20040778
  12. Weaver B, Lyon M, Blaivas M. Confirmation of endotracheal tube placement after intubation using the ultrasound sliding lung sign. Acad Emerg Med. 2006;13(3):239-244. doi:10.1197/j.aem.2005.08.014. PMID 16495415
By |2022-04-30T19:47:20-07:00May 2, 2022|ALiEMU, Pediatrics, PEM POCUS, Radiology, Ultrasound|

SmilER 104: Pericoronitis and Dry Socket

This fourth and final installment in the SmilER series covers the diagnosis and management of 2 common dental conditions that present to the emergency department: pericoronitis and dry socket.

Author: Richard Ngo, DMD
Editors: Cameron Lee, DMD, MD; Andrew Eyre, MD, MS-HPEd
Series Editor: Chris Nash, MD

How well did you learn the material? Go to ALiEMU to take the multiple-choice quizzes to receive your badges and certificates.

Learning Objectives

  1. Understand diagnostic criteria of pericoronitis and alveolar osteitis (dry socket).
  2. Understand treatment modalities for patients with pericoronitis and alveolar osteitis (dry socket).
  3. Name some of the pharmacological adjuncts to aid in recovery.
  4. Review key points to include in discharge instructions.

Diagnosis

Patients may present to the ED with pericoronitis, an inflammation of the gingival soft tissue overlying a mandibular third molar. This soft tissue is subject to trauma from the patient biting down and may lead to pericoronitis due to normal oral flora. Patients with compromised host defenses may more easily develop pericoronitis. Repeated trauma to the operculum, the soft tissue overlying a partially erupted tooth, may lead to increased swelling more easily subject to subsequent trauma—a vicious cycle leading to worsening pain and erythematous swelling. Food may also become entrapped under the soft tissue due to difficulty maintaining oral hygiene.

Pericoronitis is a clinical diagnosis and does not require imaging.

Treatment, discharge, and follow up

  1. Irrigation: In the emergency department and as an outpatient, irrigation of food debris under the operculum using chlorhexidine or normal saline can acutely reduce bacterial counts.
  2. Antibiotics: The patient can be prescribed penicillin, or clindamycin if allergic to penicillin. If not treated, pericoronitis may result in a localized soft tissue infection (see SmilER 103).

The patient should follow-up with an outpatient dentist to prevent recurrent infections. This typically involves the patient undergoing definitive treatment, that is, extraction of the offending tooth.

Diagnosis

Dry socket, also known as alveolar osteitis, is moderate to severe pain experienced after dental extraction due to exposure of bony surfaces. The pain typically begins 3-5 days following a tooth extraction. Although the cause is unclear, it is thought to be related to fibrinolytic activity within the extraction socket, which leads to lysis of the developing blood clot. The subsequent exposure of bone leads to moderate to severe pain that may be dull and aching. This pain may radiate to the ipsilateral ear. Associated symptoms include a foul odor or taste. Although dry socket is rare (2%) following routine dental extractions, it is more commonly associated with extraction of the mandibular third molars.

Dry socket diagram

Dry socket illustration for exposed bone and nerve after a blood clot is dislodged

Treatment, discharge, and follow up

Treatment of a dry socket is relatively simple. The premise is to NOT dislodge any newly forming blood clot, which serves as a protective covering.

  1. Irrigate the socket with sterile saline
  2. Gently suction away the excess saline, but do not go too deep into the socket as to evacuate the developing blood clot. The area also should NOT be curetted, as this will often worsen and possibly dislodge beneficial blood clots.
  3. Insert a medicated dry socket dressing (iodoform gauze) into the socket. These may be available in your emergency department or, alternatively, can be obtained from the pharmacy or as a commercial preparation from a dental supply company. Ingredients in this dressing include: eugenol to help with pain, topical anesthetic such as benzocaine, and a carrying vehicle such as balsam of Peru. Upon application, the patient should experience immediate relief within 5 minutes. Unfortunately, many emergency departments do not stock dry socket paste or Dressol-X. An alternative is ribbon gauze or Gelfoam impregnated with eugenol, iodine, or oil of cloves.

The patient should follow-up with an outpatient dentist or oral surgeon within 2 days to have their dry socket dressing changed every other day for the next 3-5 days.

References

  1. Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019. 
  2. Berman L, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. Mosby; 2006.
  3. Kademani Deepak. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.
By |2021-10-05T12:28:54-07:00Oct 6, 2021|ALiEMU, Dental, SmilER|

SmilER 103: Odontogenic Infections

This third module for the SmilER series covers the diagnosis and management of odontogenic infections seen in the emergency department (ED). What anatomical structures should be avoided? When is imaging necessary? What is the discharge plan?

Author: Richard Ngo, DMD
Editors: Cameron Lee, DMD, MD; Andrew Eyre, MD, MS-HPEd
Series Editor: Chris Nash, MD

How well did you learn the material? Go to ALiEMU to take the multiple-choice quizzes to receive your badges and certificates.

Learning Objectives

  1. Understand the major classifications and diagnostic criteria of odontogenic infections.
  2. Understand the indications and contraindications for computed tomographic (CT) imaging as well as incision and drainage (I&D).
    • List the materials that are required to perform an incision and drainage.
    • List some of the potential complications of incision and drainage.
  3. Name some of the pharmacological adjuncts to aid in recovery.
  4. Review key points to include in patient discharge instructions.
Diagram showing caries leading to abscess formation

Evolution of odontogenic infections, progressing from caries, pulp inflammation, to abscess formation

Odontogenic infections are infections that are dental in origin. Infections start as carious (cavitary) lesions of the dentition that spread through the pulpal tissue to develop an abscess, a purulent collection that begins at the tooth’s root. From here, the abscess may extend through the mandible or maxilla to other regions of the mouth, face, and the rest of the body through the fascial planes of the head and neck.

Diagram showing abscess formation around the roots of the maxillary incisors

(A) Periradicular (around the root) infection in a maxillary incisor with the root apex close to the facial aspect of the maxilla results in erosion of the facial cortex and an abscess in the vestibular space. (B) Maxillary incisor with the root apex closer to the palatal cortex, increasing the likelihood of palatal cortical erosion and palatal abscess. [1] 

Abscess vs Cellulitis

An abscess is a localized, fluctuant mass that can be palpated upon physical examination. In contrast, cellulitis is characterized by diffuse induration without purulence. In both cases, patients may be febrile and may exhibit erythema or warmth of the infected site. Abscesses benefit from incision and drainage treatment, while antibiotics alone are sufficient for cellulitis.

Incision and Drainage (I&D)

For abscesses, the most important therapeutic intervention is the I&D of purulent material. The technique and approach is similar to the I&D of skin and soft tissue abscesses in other parts of the body. For odontogenic infections, I&D also changes the previously anaerobic environment into an aerobic one, thus making it difficult for anaerobic microbes to survive. As with skin and soft tissue abscesses, antibiotic therapy is a necessary adjunct to proper drainage.

Buccal abscess

Buccal space abscess spontaneously draining through the skin of the cheek (path of least resistance) [1]

.

Fascial Planes

The head and neck regions have many fascial planes containing potential spaces by which pus or cellulitis from odontogenic infections may spread. Major anatomic groups include: the midface, cheek and lateral face, mandible and below, and pharyngeal and cervical areas. Once eroded through bone, an infection can express itself in various places depending on the the relationship of muscle attachments to the site of perforation. Regions beyond the local buccal and vestibular spaces of the oral cavity should be escalated to specialty care, given anatomy complexity and potential risk for airway compromise or irreversible damage to anatomic structures.

Masticator Space Abscess

One example of a deep space that may become infected and requires specialty consultation is the masticator space. The masticator space is a general term that includes the any of the following spaces:

  • Pterygomandibular space
  • Submasseteric space
  • Superficial temporal space
  • Deep temporal space

The boundaries of the masticator space consists of the muscles of mastication, which including the following:

  • Masseter muscle
  • Medial and lateral pterygoid muscles
  • Temporalis muscle

The superficial and deep temporal spaces are separated from each other by the temporalis muscle. The lateral pterygoid muscle divides the pterygomandibular space from the infratemporal portion of the deep temporal space. The zygomatic arch divides the submasseteric space from the superficial temporal space. Abscesses within any of the components of the masticator space will require surgical drainage in an operating room under general anesthesia and should not be attempted in the ED.

The above axial cross-section diagram marks other extraoral regions which require specialty consultation. The fascial planes of the head and neck region may serve as potential pathways for the spread of infection into deeper spaces. As an example, the retropharyngeal space (yellow area in diagram above) allows for the potentially dangerous extension of infection into the mediastinum.

Part 1: History

Proper diagnosis of odontogenic infection in the ED begins with a thorough medical and dental history (see the Oral Examination and Local Anesthesia course). Additionally, ask about the course and progression of the swelling, dysphagia, odynophagia, dyspnea, foul breath or taste, and any immunocompromising conditions.

Part 2: Examination

Suction, irrigate, and examine the oral cavity thoroughly. Palpate any intraoral or extraoral masses to assess fluctuance or induration. Also note the following:

  • Location of swelling and dental pain
  • Floor of mouth elevation or induration
  • Uvular deviation
  • Periorbital swelling
  • Orbital proptosis

Measure the maximal incisal opening by asking patients to open their mouths as wide as possible; this is the greatest distance between the incisal edge of the maxillary central incisor and the incisal edge of the mandibular central incisor. A normal adult mouth opening is between 30-40 mm. Trismus, or reduced mouth opening, should raise concern for a potential deep space infection.

Measuring the maximal incisal opening with a ruler, between the incisal edges of upper and lower central incisors.

Measuring the maximal incisal opening, between the incisal edges of upper and lower central incisors.

A crucial odontogenic infection-related physical exam finding includes blunting of the inferior border of the mandible at the body; this is significant facial swelling that prevents the provider from palpating the bony structures at the body of the mandible.

Mandibular Anatomy

Anatomy of the mandible. An important exam finding includes swelling of the soft tissues overlying the body of the mandible.

Part 3: Imaging

Computed tomography (CT) imaging is indicated if there is concern for an odontogenic infection involving a deep fascial space. Two physical exam findings help predict when CT imaging is warranted [2].

  1. Blunting of inferior border of the mandibular body
  2. Trismus, as determined by maximum incisal opening <25 mm
Algorithm to determine need for CT vs Radiographs

Algorithm to determine whether CT imaging for odontogenic infection is necessary

If CT is not indicated, a Panorex panoramic radiograph is sufficient.

It can be challenging to determine when a patient’s odontogenic infection warrants specialist consultation in the ED, operative treatment, or inpatient admission.

High risk odontogenic infections

The patient will require inpatient admission and likely operative treatment for these following conditions in the setting of an odontogenic infection:

  • Involvement of the airway or deeper fascial spaces
  • Rapid progression of the infection
  • Need for general anesthesia
  • Dehydration or the inability to take fluids orally
  • Trismus
  • Immunocompromised status
  • Lack of improvement on oral antibiotics

These patients should be monitored for progression of the infection, as cases may rapidly progress to life-threatening conditions. If the infection is evident on the skin, mark the edge of the erythematous regions of the infection to monitor spread.

Odontogenic infections which do NOT require specialty consultation

Intra-oral maxillary and mandibular vestibular and buccal space swellings are infections limited to relatively safe, low-risk areas. These abscesses are amenable to incision and drainage by the emergency physician under local anesthesia. These are fascial spaces that will not cause airway obstruction and generally do not require general anesthesia or extraoral incisions to achieve adequate drainage. In these cases, patients normally do not complain of trismus, difficulty breathing, or swallowing. CT imaging is usually unnecessary.

1. Vestibular Abscess

Vestibular abscesses are infections that spread through bone to buccal tissues when the apex of the involved tooth is within the confines of the buccinator muscle attachment. The infection remains between the oral mucosa and the nearby facial muscle.

2. Buccal Abscess

3. Buccal Space Abscess

The buccal space lies superficial to the buccinator muscle and deep to the overlying skin and subcutaneous tissue. In these cases, the involved tooth’s apex is either superior or inferior to the insertion of the buccinator muscle. This potential space may become involved via infection of maxillary or mandibular molars.

A) When the tooth root apex is within the confines of the attachment for the buccinator muscle (in red), a vestibular space abscess localized medial to the buccinator muscle results. 

B) When the tooth root apex is outside of the confines of the attachment for the buccinator muscle (in red), a buccal space abscess localized lateral to the buccinator muscle results.


Odontogenic infections which DO require specialty consultation

Progression of infections to deeper spaces beyond the vestibular and buccal spaces increases the severity of the infection and thus requires specialty consultation. Indications for specialty consultation include any of the following:

  • The spread of infection to potentially dangerous fascial spaces, potentially leading to airway compromise
  • Difficulty swallowing
  • Trismus
  • Systemic signs of infection, such as a toxic appearance, respiratory distress, or altered mental status

In these cases, CT imaging is usually needed to determine the location and extent of the infection.

What deep space areas are especially dangerous?

Dangerous fascial planes include infection which spread:

  • Beyond the alveolar process (such as to the submental, sublingual, or submandibular spaces)
  • To the palatal spaces (medial relative to the maxillary dentition)
  • To the masticator space involving the muscles of mastication
  • To the more posterior oropharyngeal/retropharyngeal spaces
  • To the superiorly-located sinuses or orbital spaces
  • To any nearby vital structures such as major nerves and arteries (mental, lingual, facial, and ophthalmic bundles).

When in doubt, CT imaging should be obtained to determine proximity to nearby vital structures. In more severe cases, odontogenic infections may potentially lead to but are not limited to cavernous sinus thrombosis, Ludwig’s angina (the bilateral involvement of the submandibular, sublingual, and submental spaces), sinusitis, brain abscess, or mediastinitis. These more severe cases often require airway management, CT imaging, IV antibiotics, or emergent I&D in the operating room by specialty surgical services.

Examples of High-Risk Cases

The following figures indicate common regions involved in odontogenic infections for which escalation of care with specialty consultation is recommended. These complex infections include: palatal space abscesses on the palate of the mouth medial to the maxillary dentition, sublingual and submandibular space abscesses inferior to the tongue and floor of mouth, and abscesses that extends superiorly to involve the sinuses or orbits. To reiterate, any abscess requiring an extra oral approach for management requires specialist consultation.

Abscesses in the Mandibular Premolar Region:

Abscesses located in the mandibular premolar region are located near the mental neurovascular bundle. Those that require I&D need a cautious approach to avoid this vital structure. These may be better served by drainage by a consulting dentist or oral surgeon. 

Palatal Space Abscesses:

Found medial to the maxillary dentition. I&D should be escalated to specialty care to avoid damaging the greater and lesser palatine neurovascular bundles.

Sublingual Abscesses:The sublingual space lies between the oral mucosa and the mylohyoid muscle and can become infected from the mandibular premolar and first molar teeth. I&D should be escalated to specialty care as abscesses in this space are at high risk for rapid spread and airway compromise.

Submandibular Abscesses:

The submandibular space lies between the mylohyoid muscle and anterior layer of the deep cervical fascia, just deep to platysma muscle. It includes the lingual and inferior surfaces of the mandible below the mylohyoid muscle attachment. I&D should be escalated to specialty care as abscesses in this space are at high risk for rapid spread and airway compromise.

Potential risks for incision and drainage (I&D) should be discussed with the patient and informed consent obtained. These risks include but may not be limited to pain, bleeding, swelling, scarring, damage to adjacent anatomic structures, nerve damage, and the need for additional procedures.

Steps

  1. Examine the oral cavity for any foreign material.
  2. Suction out any blood, saliva, and purulence.
  3. Irrigate the oral cavity with copious normal saline.
  4. Administer local anesthesia should be administered via a regional block and/or into the mucosa adjacent to the site of infection. Be careful not to pass the needle from infected to uninfected tissue to avoid the unintended inoculation of offending bacteria. Additional anesthesia may be required in the setting of infection. If the initial level of anesthesia is suboptimal, partially drain the abscess and irrigate to remove some of the pus. This can improve the acidic pH of the infection, allowing for additional local anesthetic to be more effective.
  5. Palpate the abscess to determine where the incision would obtain maximum drainage.
  6. Make a 1- to 2-cm incision perpendicular to the underlying bone at the height of fluctuance, while avoiding any major anatomical structures.
    • Maxillary vestibular abscesses: Placing the incision in a dependent (inferior) position prevents incomplete drainage. Upon evacuation of pus, a syringe can be used to collect cultures to be sent for sensitivity analysis. Submucosal spreading to break open any loculations with a curved hemostat should be performed. Finally, irrigate the surgical site copiously.
Maxillary Vestibular Abscess

For a maxillary vestibular abscess, an incision at a dependent, inferior position (green arrow) helps to prevent incomplete drainage from the pooling of the purulence on the inferior aspect of the abscess cavity. An incision at a non-dependent, superior position (red arrow) may lead to pooling of purulence and inadequate drainage.

I&D Technique

Incision and drainage technique for vestibular abscess. (A) Periapical infection of a mandibular premolar (note buccal cortical erosion superior to the buccinator muscle attachment). (B) Incision made into fluctuant swelling to the depth of the abscess cavity. (C) Curved hemostat used in opening motion in various directions to break loculations of purulence within the abscess cavity. (D) Optional: insertion of a Penrose drain (1 cm diameter) into the depth of the abscess cavity. (E) Optional: suturing of the drain with a single nonabsorbable suture (3-0 silk).

Oral Hygiene

Patients should be prescribed chlorhexidine 15 mL swish and spit, twice daily for 1 week.

Antibiotics

Mixed aerobic and anaerobic bacteria cause most odontogenic infections. Antibiotics are an adjunct but not a replacement for incision and drainage in odontogenic abscess management. Antibiotics are particularly important for immunocompromised patients.

  1. Oral amoxicillin 500 mg TID for 3-7 days
  2. Alternative: Oral penicillin V potassium 500 mg QID for 3-7 days
  3. If first-line treatment fails: Either broaden the antibiotic therapy by adding oral metronidazole 500 mg TID for 7 days, or discontinue first-line treatment and prescribe oral amoxicillin 500 mg and clavulanate 125 mg (Augmentin) TID for 7 days.

 What if the patient has a penicillin allergy?

  • Inquire whether the patient has a history of anaphylaxis, angioedema, or hives with penicillin, ampicillin, or amoxicillin.
  • If the patient does not have any history of these severe allergic reactions, prescribe oral cephalexin 500 mg QID for 3-7 days.
  • If the patient does have such an allergic history, then prescribe oral azithromycin with a loading dose of 500 mg for one day, followed by 250 mg for an additional 4 days. An alternative to this would be oral clindamycin 300 mg QID for 3-7 days. If first-line treatment fails, then broaden antibiotic therapy to by adding oral metronidazole 500 mg TID for 7 days.

Pain Management

Postoperative pain can be managed with ibuprofen and/or acetaminophen. Peak swelling and inflammation is expected roughly 48 hours post-procedurally.

Follow-up

The patient must be instructed to follow up with an outpatient dentist as soon as possible to address the underlying cause of the infection. A root canal treatment or extraction of the offending tooth will likely be necessary to achieve source control of the infection. Failing this, the patient is likely to return to the ED with a recurring infection. Reasons for return to the hospital may include but are not limited to inadequate drainage with residual undrained loculations, spread of infection to deeper fascial planes, inappropriate antibiotic choice or dosage, or issues related to patient compliance.

References

  1. Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019.
  2. Christensen BJ, Park EP, Suau S, Beran D, King BJ. Evidence-Based Clinical Criteria for Computed Tomography Imaging in Odontogenic Infections. J Oral Maxillofac Surg. 2019;77(2):299-306. PMID: 30347202
  3. Berman L, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. Mosby; 2006.
  4. Kademani D. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.
By |2022-09-22T06:43:34-07:00Sep 30, 2021|ALiEMU, Dental, SmilER|

SmilER 102: Dental Trauma

This second module for the SmilER series covers the management of common dental trauma cases seen in the emergency department (ED). What should you do with the various types of dental fractures and avulsions, how do you manage them in the ED, and what sort of follow-up should the patient receive?

Author: Richard Ngo, DMD
Editors: Cameron Lee, DMD, MD; Andrew Eyre, MD, MS-HPEd
Series Editor: Chris Nash, MD

How well did you learn the material? Go to ALiEMU to take the multiple-choice quizzes to receive your badges and certificates.

Learning Objectives

  1. Understand the major classifications and diagnostic criteria of dental traumatology for adult patients.
  2. Understand reimplantation of avulsed teeth, as well as splinting for adult dental-related trauma.
    • List the materials that are required to place a dental splint.
    • List some of the potential complications of splinting.
    • Understand imaging required for dental-related trauma cases.
  3. Name some of the pharmacological adjuncts to aid in recovery.
  4. Review key points to include in patient discharge instructions after dental trauma.

Part 1: History

Proper diagnosis of dental trauma in the ED begins with a thorough medical and dental history (see the Oral Examination and Local Anesthesia course).

Part 2: Examination

  • Suction and irrigate the oral cavity thoroughly.
  • Maintain the patient’s airway while assessing and removing potential aspiration risks, including significantly loose or displaced dentition.
  • Identify all fracture fragments, since they may be lodged into soft tissues or intruded into alveolar bone.
  • Hemorrhage control can be achieved with gauze and direct pressure. Escalate care to specialists if you are unable to achieve hemostasis.
  • Assess the parotid and sublingual ducts for possible lacerations. Trauma to these areas could potentially lead to sialadenitis (salivary gland inflammation).
  • Poor occlusion (bite) may be indicative of mandibular or maxillary fractures.

Part 3: Imaging

A chest x-ray should be obtained if there is concern for aspiration. Panoramic imaging is helpful to visualize the dentition and also should be assessed for mandibular fractures. For all cases requiring intervention, the provider should obtain pre- and post-procedural imaging.

The traditionally-taught Ellis classification system is falling out of favor. More recently, fractures of both primary and permanent teeth are classified as either uncomplicated or complicated fractures. A fracture is defined as complicated if it involves the pulp.

Tooth fracture classification (modified from [1])

Uncomplicated enamel fractures are fractures in the tooth that do not extend to the dental pulp. These fractures tend to be asymptomatic and do not require urgent attention. This may include infractions, also known as craze lines. An infraction is an incomplete fracture through the enamel. It is asymptomatic and does not require further treatment. In general, uncomplicated fractures of only the enamel simply require observation and follow-up with an outpatient dentist.

Uncomplicated Fractures of the Enamel-Dentin

Simple uncomplicated fractures can extend into the enamel and/or dentin, but avoid penetration to the pulp. Patients can be advised to keep tooth fragments for potential re-bonding as a temporary restoration at an outpatient dental clinic. If a tooth fragment is brought into the ED, it may be re-bonded as a temporary measure. This can be completed in the hospital by consulting the OMFS or dental services. Alternatively, this can be completed by a dentist in the outpatient setting.

Enamel-Dentin-Pulp Fractures

Enamel-dentin-pulp fractures in the tooth that result in the exposure of dental pulp to the oral cavity. Patients often complain of significant pain or sensitivity. These cases require either root canal treatment or extraction of the offending tooth by an outpatient dentist. If this is not properly performed, the patient is likely to return to the ED with an infection or worsened dental pain. If calcium hydroxide is available, this can be applied to the surface of the pulpal exposure. These patients should follow-up with an outside dentist, preferably within 1 week following discharge from the emergency department.

Complicated Dental Fracture

Complicated dental fracture involving the pulp and an uncomplicated fracture through just the enamel in the same tooth. 

Root Fractures

Root fractures are complicated fractures of the tooth root. Patients often have pain and tenderness upon percussion of the offending tooth. The coronal segment may be mobile/displaced, in which case a splint is recommended for at least 4 weeks.

If the tooth is non-mobile (fracture likely in the apical third of the root), no immediate treatment is necessary. Of note, it is possible to have a root fracture even if the visible, manipulable portion of the tooth is not mobile. An outpatient dentist must thoroughly evaluate these patients with proper imaging equipment (e.g., periapical radiographs) that are typically not available in emergency departments.

These patients should follow-up with an outside dentist, preferably within 1 week following discharge from the emergency department.

Alveolar Fractures

Alveolar fractures are complicated and involve the bone surrounding the dentition, also known as the alveolus. The hallmark of this injury is that upon manipulating a single tooth, an entire segment of teeth and bone will move simultaneously. Patients may also present with concurrent fracture or luxation injuries. OMFS consultation is recommended for these cases, because a complex arch bar placement is often necessary for proper stabilization and treatment.

Displacement classifications include concussion, subluxation, luxation, intrusion, and avulsion. Cases involving avulsion are time-sensitive and require urgent attention for the best prognosis.

Concussion

Concussion is an injury to tooth-supporting structures without displacement or mobility of the tooth. These teeth exhibit pain to percussion. Concussed teeth generally do not require emergency treatment unless the tooth becomes dark or black; these patients should follow up with an outpatient dentist for potential root canal treatment.

Subluxation

Subluxation is mobility of a tooth without significant displacement of the tooth from its original position. These cases involve injury to the tooth-supporting structures, which result in abnormal loosening without displacement. These teeth, if permanent ones, should be placed in a dental splint for at 2 two weeks.

Intrusion

Intrusion involves movement toward the root (superiorly for maxillary teeth and inferiorly for mandibular teeth). OMFS consultation is highly recommended for cases involving intrusion, as complex surgical manipulation and re-positioning may be required. Of all types of luxation injuries, intrusions are the most likely to require long-term treatment by dental specialists.

Lateral Luxation/Extrusion

Lateral luxation involves displacement of the tooth from its original position (usually anteriorly or posteriorly), and extrusion is displacement from the sock in the coronal direction. These teeth, if permanent ones, should be repositioned and placed in a dental splint for at least 2 weeks.

Lateral Luxation Diagram

Eccentric displacement of the tooth seen in lateral luxation. Displacement of the tooth anteriorly or posteriorly is often associated with alveolar wall fractures. 

Avulsion

Avulsion is the complete displacement of the tooth out from its original socket in the alveolar bone. If the patient arrives with an avulsed tooth, it is important to ask the patient how long the tooth has been avulsed. If the patient cannot be seen immediately, the avulsed tooth or teeth should be placed in saline, milk, or water (in that ordered preference).

The physician should avoid handling or wiping the root (handle by the crown only) to maintain the vitality of periodontal ligament cells and maximize chances for successful re-implantation and re-integration of the tooth.

If the tooth has been out of the socket for more than 20 minutes:

  1. Place it into saline for 30 minutes. This appears to reduce the incidence of ankylosis by improving the survivability of the cells on the root of the tooth.
  2. Then soak it in a doxycycline solution (1 mg/20 mL saline) for 5 minutes. The doxycycline helps to inhibit bacterial growth in the pulp, which reduces chances for revascularization.
  3. Attempt re-implantation. The tooth can be replanted slowly with slight, careful digital pressure.
  4. Place a dental splint.

Possible complications of re-implanted avulsed dentition include enamel hypoplasia, hypocalcification, crown/root dilaceration, and eruption pattern disruption. Long-term prognosis is negatively correlated with the length of time that the tooth has been avulsed from its socket. Once out of the socket for over an hour, it becomes unlikely that the tooth will re-integrate to the bone without complications.

Although many emergency departments do not have access to typical dental supplies, providers who do have access to these supplies should follow instructions as described below. For those who do not, you might consider having your department invest in these supplies.

Supplies

  • Curing light
  • Etching material
  • Bonding material
  • Flowable composite
  • Stainless steel wire
  • Wire cutters

Splinting Steps

  1. Etching
  2. Priming/bonding
  3. Curing of flowable composite to hold the dental wire in place

Screenshots from Dundee Dental School YouTube video (shown below).

Cut Wire to Length

1. Cut the wire and contour it to fit the dental arch

Etch the teeth

2. Etch the surfaces to be bonded with flowable composite to create the proper porosity necessary for bonding. After 30 second, the teeth should be irrigated thoroughly with saline.

Apply bonding agent

3. Apply bonding agent to the previously etched surfaces

Cure the bonding agent

4. Cure the bonding agent for 30 seconds. The chemical reaction within the bonding agent is initiated by blue light. Be sure not to look directly into the light as it can damage the retina.

Position the composite and wire in the desired location

5. Apply the flowable composite to the mobile tooth and at least 2 adjacent teeth flanking the mobile tooth. Make sure you splint the teeth their ideal location (where it looks most natural). Cure for 30 seconds to finalize the splint. A post-procedure panoramic radiograph should be obtained if available at your institution. 

Video Summary of Splinting Steps

Not every hospital has access to high-quality dental equipment, and your emergency department may not have the necessary supplies to create a composite and wire splint. In that case, you’re still in luck! Check out this ALiEM Trick of the Trade by Dr. Hans Rosenberg and published in Annals of Emergency Medicine about using equipment that you will have in your ED to fashion a temporary splint. All you need are an N95 mask and tissue glue adhesive.

Close up repair dental avulsion

Dentist Follow-Up Care

Following splinting of dental trauma, the dentition may or may not be salvageable in the long term. However, the patient must follow-up with a dentist as soon as possible for a more thorough dental examination and long-term care. Although dentition may appear to be stable on physical examination and imaging in the ED, providers should inform patients of the possibility that dental fractures may not be visible without more thorough imaging at an outpatient dental clinic, ideally within a 2-week timeframe or sooner.

Pain Management

Regarding postoperative pain management, ibuprofen can be prescribed in combination with acetaminophen. The patient will experience peak swelling and inflammation roughly 48 hours after the procedure. The patient should be instructed to ice the area to minimize swelling without wetting the splint for the first 24 hours following discharge.

Oral Hygiene

Chlorhexidine 0.12% 15 mL can be used to rinse the mouth twice daily for 1 week. Using chlorhexidine for longer than this is not recommended as staining of the dentition may occur.

Diet

The patient should be placed on a soft diet and avoid chewing in the area of the splint until further instruction by their dentist.

No Antibiotics

Antibiotics are not generally recommended following dental trauma except for avulsion injuries.

References

  1. Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019.
  2. Berman L, Blanco L, Cohen S. A Clinical Guide to Dental Traumatology. Mosby; 2006.
  3. Kademani D, Tiwana P. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.
  4. Dundee Dental School. Composite and Wire Splint. Part1: Placement. YouTube; 2018.

By |2021-09-21T16:48:06-07:00Sep 22, 2021|ALiEMU, Dental, SmilER|

SmilER 101: Oral Exam and Regional Anesthesia in Dental Care

The purpose of the SmilER series on dental trauma and infection management is to teach fundamental principles, pearls, and pitfalls in the care for dental patients in the emergency department. As many as 1.5% of ED visits are dental-related¹ and many emergency physicians have expressed the need for more comprehensive training in the oral cavity. This series was created as an introductory guide on the management of patients who report to the ED with dental-related conditions. The first module teaches the oral examination and demonstrates how to provide anesthesia in the oral cavity.

Author: Richard Ngo, DMD
Editors: Cameron Lee, DMD, MD; Andrew Eyre, MD, MS-HPEd
Series Editor: Chris Nash, MD

Learning Objectives

  1. Review basic anatomy of the oral cavity.
  2. Understand how to perform a basic oral examination.
  3. Learn to perform basic regional anesthesia to each region of the oral cavity.

How well did you learn the material? Go to ALiEMU to take the multiple-choice quizzes to receive your badges and certificates.

Adult

The typical adult oral cavity contains 32 teeth split into 4 sections, with each quadrant containing 2 incisors, 1 canine, 1 premolars, and 3 molars. The universal numbering system labels dentition with numbers from 1 through 32 starting with the right maxillary third molar. When assessing the oral cavity for avulsed or damaged dentition, it is essential to note some individuals may have congenitally missing teeth or may have had dentition extracted in the past due to various reasons. Premolars can be found anterior to the molars, and they are smaller in width.

Adult Dental Anatomy Chart

Permanent dentition named and numbered (modified from Shutterstock)

Pediatric

Whereas adults have 32 teeth, pediatric patients have 20 primary teeth, labeled A through T. Pre-adolescents have mixed dentition, consisting of both deciduous (“baby” or “primary”) dentition and succedaneous (“permanent”) dentition. Most pediatric patients will have lost all of their primary teeth by 12 years of age.

Tooth Anatomy

Each tooth follows the same overall anatomical structure, as seen in the diagram below. However, the shape, number of roots, function, and other attributes vary from tooth to tooth. When referencing dentition, coronal is the portion of the tooth towards the crown. On the other hand, apical (as in apex) is the portion of the tooth towards the root.

A thorough oral examination is essential in the ED assessment of patients with dental complaints. When assessing the oral cavity for avulsed or damaged dentition, it is essential to note that some individuals may have congenitally missing teeth or may have had dentition extracted in the past. Obtaining a thorough dental history and oral examination may help to alleviate any potential confusion regarding special anatomical considerations. Note findings such as absence of teeth, poor/damaged dentition, supernumerary teeth, extracted teeth, and tori.

This diagram reveals the eight regions of the oral cavity that the provider should examine carefully. Manual manipulation of the tongue is easier when gauze is used to obtain a steadier grip. A tongue depressor is recommended for examination of the posterior oropharynx.

Oral Tori

Oral tori are uncommon but normal variants of bone found along the palate or lingual aspect of the mandible. They are bony structures in the hard palate or the mandible, as shown below. It is important to know that these structures exist so as to avoid being unnecessarily alarmed.

Photo and CT Scan of a Torus Palatinus

Torus seen on the hard palate [exam, CT image]

Maxillary Tori photo and a CT scan demonstrating the same

Maxillary tori [exam, CT image]

Notably, tori differentiate themselves from cancers and abscesses in a few ways.

  1. Tori are typically bony to the touch as they arise from bone. In contrast, abscesses and soft tissue cancers are more fluctuant and/or softer than bone.
  2. Tori are typically symmetrical from side to side.
  3. Tori are typically asymptomatic.

Local anesthesia is necessary before splint placement, incision and drainage, or any other procedure which involves significant and painful dental manipulation. It may also be used for temporary relief of substantial pain. Note that this is not a long-term solution but simply a temporary measure to bridge a patient to an outpatient dental appointment. In these cases, bupivacaine is recommended due to its longer half-life. The maximum dosage of local anesthetics should be calculated prior to administration (MDcalc).

With appropriate dosing and administration, you shouldn’t have to worry about toxicity, but you can read more about local anesthetic systemic toxicity (LAST) to be extra prepared.

Supraperiosteal Block

Anesthesia of the maxillary dentition is achieved through supraperiosteal (“local”) infiltration of lidocaine. tThe maxilla is more porous than the mandible, allowing easier penetration of the bone and anesthesia of the dentition.

1. Anterior Maxilla

Administration of local anesthesia to the anterior maxillary dentition can be particularly painful for patients given the extensive neural anatomy of the nose. Thus, it is essential to begin laterally and work in a stepwise fashion medially. Additionally, one can consider topical anesthesia with viscous lidocaine or benzocaine before using the needle.

2. Posterior Maxilla

For posterior maxillary teeth, use a short needle to minimize the risk for developing a hematoma. Taut retraction of the lip and the attached mucosa provides tension which makes needle penetration easier. Additionally, retraction activates proprioceptive fibers, which helps distract the patient from the pain of needle insertion.

Supraperiosteal Block: Site of local anesthetic deposition for infiltration technique to anesthetize regions of the maxilla. Source: NYSORA.COM

Technique

  1. Aim for the tooth apex and advance the needle while maintaining a needle position parallel to the long axis of the tooth.
  2. Penetrate the mucogingival junction with the bevel pointing towards the bone.
  3. Make contact with bone.
  4. Aspirate.
  5. Inject 1-2 cc of anesthetic.

Inferior Alveolar Nerve Block

The inferior alveolar nerve (IAN) is a branch of the mandibular nerve (V3 of the trigeminal nerve). Anesthesia of this nerve will result in anesthesia of the ipsilateral mandibular teeth to the midline, as well as the skin and mucous membranes of the lower lip, skin of the chin, and the labial gingiva of the anterior teeth. The goal is to inject local anesthetic in the region of the IAN before it enters the mandibular foramen at the medial aspect of the mandible.

Landmark Anatomy

The following figures help to clarify major anatomical landmarks for the IAN block:

IAN Landmarks

Inferior Alveolar Nerve Block: Pay attention to the site of entrance of the alveolar nerve into the mandible, and note the coronoid notch as an important landmark.

Inferior Alveolar Nerve Block Landmarks

Inferior Alveolar Nerve Block: The pterygomandibular raphe is a useful landmark to guide the intraoral injection point. When the patient’s mouth is held as wide as possible, the raphe tenses and becomes a visible reference line. The injection point (labeled with an X above) should be just lateral to the line so that the needle does not penetrate the raphe itself. An optional pre-step is to apply topical anesthesia with viscous lidocaine or benzocaine at the planned injection site prior injection.

Technique

  1. Place the thumb in the ipsilateral coronoid notch and visualize a line extending from the thumb back to the pterygomandibular raphe (roughly two-thirds up the finger nail).
  2. Keep the needle parallel to the occlusal plane with the bevel positioned away from the bone.
  3. Enter with the syringe oriented on the contralateral mandibular premolars.
  4. Insert the needle 1 cm above the occlusal plane and 3-5 mm lateral of the pterygomandibular raphe.
  5. Advance the needle 20-25 mm to sound bone.
  6. Retract 1-2 mm.
  7. Aspirate.
  8. Inject 75% of the total dose in this region.
  9. While removing the needle, inject the remaining 25% dose to anesthetize the lingual nerve. The total amount injected will be approximately 1-2 cc of anesthetic.
  10. Ensure adequate anesthesia by testing the patient for any acute pain upon manipulation. Keep in mind that it may take up to 5 minutes for the block to take effect following administration.

Of note, given its proximity to the IAN, the lingual nerve is also sometimes anesthetized during this block. This leads to anesthesia of the anterior two thirds of the tongue, the lingual gingiva, and the mucosa of the floor of the mouth.

Adjunctive Blocks

  1. Mandibular Incisors: The IAN block is typically sufficient to anesthetize the ipsilateral mandibular dentition and soft tissues. However it can somestimes under-anesthetize the mandibular incisors, If this occurs, we recommend adjunctive supraperiosteal blocks, as noted in the previous section. Note that supraperiosteal blocks, while useful in the maxilla, will not reliably attain complete anesthesia of the mandibular dentition as the mandible is less porous.
  2. Lips: The mental block is useful for the soft tissues of the lip anteriorly

Peer Reviewed

All information has been expert peer-reviewed by an oral and maxillofacial surgeon. 

Reference

  1. Hupp J, Ellis E, Tucker M. Contemporary Oral and Maxillofacial Surgery. Elsevier; 2019.
  2. Kademani D, Tiwana P. Atlas of Oral and Maxillofacial Surgery. Saunders; 2015.
By |2021-09-15T06:17:56-07:00Sep 15, 2021|ALiEMU, Dental, SmilER|

ALiEM AIR Series | Endocrine 2021 Module

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Welcome to the AIR Endocrine Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to endocrine emergencies in the Emergency Department. 7 blog posts met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 4 AIR and 3 Honorable Mentions. We recommend programs give 3.5 hours (about 30 minutes per article) of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

 

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

Interested in taking the Endocrine quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Endocrine Emergencies

SiteArticleAuthor(s)April 10, 2021Label
EMCritWernicke’s EncephalopathyJosh Farkas, MDOctober 14, 2020AIR
EMCritHyperosmolar Hyperglycemic State (HHS)Josh Farkas, MDJuly 31, 2020AIR
EMDocsHyperglycemic Hyperosmolar State: ED presentation, evaluation, management, and complicationsRachel De Andrande Pereira, MD, Muhammad Waseem, MD, and Mushtaq Godil MDJanuary 2, 2020AIR
DFTBDiabetic KetoacidosisDani Hall, MDJanuary 27, 2020AIR
ALiEMIs Lactated Ringer’s Solution Safe for Hyperkalemia Patients?Bryan Hayes, PharmD, DABAT, FAACT, FASHP and Mike O’Brien, PharmDApril 10, 2021HM
EMDocsDecompensated Hypothyroidism: Why do we miss it, and how do we improve?Faiz Ahmed, MD and Brian Meier, MD, MSc-GHNovember 30, 2020HM
EMDocsCritical Hyponatremia: Pearls and PitfallsNikita Desai, MD and David Jang, MDJanuary 13, 2020HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

If you have any questions or comments on the AIR series, or this AIR module, please contact us! More in-depth information regarding the Social Media Index.

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

GroundED in EM: A new ALiEMU course series for third-year medical students

GroundED in EM curriculum medical student

During the pandemic, similar to how a work-from-home mentality has become more accepted, a learn-on-own mentality has arisen for medical students. The success of the 9-part Bridge to Emergency Medicine (EM) self-guided curriculum for senior medical students interested in EM has confirmed this. This was evidenced by over 130,000 page views about the Bridge curriculum since March 2020 and 609 awarded ALiEMU certificates since April 2021 (launched only 2 months ago!).

GroundED in EM: A new curriculum for third-year medical students

We are thrilled to announce a 4-week, self-guided reading/listening curriculum along with choose-your-own-adventure cases paired now with ALiEMU quizzes, certificates, and badges for third-year medical students interested in EM. It’s called GroundED in EM, and created by an all-star team led by GroundED Editor-in-Chief, Dr. Andy Little. Here’s the rest of the team:

Editors:

  • Brian Barbas, MD, FACEP (Associate Professor of Emergency Medicine, Loyola University Chicago – Stritch School of Medicine)
  • Carmen J. Martinez, MD MSMEd (Assistant Professor of Emergency Medicine, University of South Alabama)
  • Guy Carmelli, MD, MSEd (Assistant Professor of Emergency Medicine, University of Massachusetts)
  • Laryssa A. Patti, MD (Assistant Professor of Emergency Medicine, Rutgers Robert Wood Johnson Medical School)

Adventure Co-Creators:

  • Kaitlin Bowers, DO (Vice Chair of Emergency Medicine, Campbell University College of Osteopathic Medicine)
  • Meenal Sharkey, MD FACEP (Assistant Program Director & Clerkship Director; Department of Emergency Medicine, Doctors Hospital)

GroundED on ALiEMU

Similar to Bridge to EM, reading and listening materials have been identified and curated from external sites. Then come on back to ALiEMU to take self-assessment quizzes to get your certificates and badges.

By |2021-06-22T13:20:35-07:00Jun 22, 2021|ALiEMU, Medical Student|
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